Addressing complex healthcare problems in diverse settings: Insights from activity theory
Introduction
In the UK, theories of organisational learning and knowledge management have been particularly influential in recent attempts to reform health and other public services (Office for Public Service Reform, 2002). Theories underpinned by notions of knowledge transfer and/or knowledge translation (henceforth referred to as ‘KT theories’) dominate current approaches to policy implementation, service improvement and quality assurance (Department of Health, 2000, SEHD, 2000, SEHD, 2001a). The applicability and usefulness of these theories are increasingly questioned given the distributed knowledge base, diverse settings and complex, fragmented nature of healthcare work (Marchington et al., 2005, Tsoukas, 1996, Walker, 2007).
In this paper we propose activity theory (henceforth ‘AT’) as an alternative theoretical approach which illuminates the contested, negotiated nature of healthcare policy, management and clinical work and accounts for some of the difficulties experienced with KT-informed policy and managerial practices. We suggest that an activity theoretical approach enables the relations between policy making, management and clinical work to be understood in new ways, revealing the generative potential of tensions between these three interlinked and overlapping areas of practice. Rather than seeking strict conformity to ‘best practice’, AT highlights the value of variation and even contradictions for practice development.
We begin by outlining key features of KT theories and then present AT as an alternative theoretical perspective. We then illustrate the explanatory and practical utility of AT by drawing on an empirical study of collective learning in primary care teams. In particular we show how AT could account for and suggest ways of moving beyond failures of policy implementation that seem paradoxical according to KT.
Section snippets
Knowledge transfer theories
In the field of organisation studies, there has been significant debate concerning how knowledge is acquired and spread in organisations. The notion of ‘knowledge transfer’, which originated in literature on organisational learning and knowledge management (Argote et al., 1990, Argote and Ingram, 2000), has featured prominently in healthcare policy and management, particularly in the USA and UK (Harrison, Moran, & Wood, 2002). It has been augmented by the concept of knowledge translation, which
Empirical example
Many Western countries have high levels of acute hospital admissions of older people which are considered inappropriate: older people may need care and support due to health-related problems, but not necessarily high-tech hospital care. Inappropriate admissions arise against a backdrop of increasingly fragmented service provision (World Health Organisation, 2008). Their various unwanted personal, organisational and policy-related implications include iatrogenic harm, ‘blocked’ hospital beds,
Methods
We analysed attempts to achieve the policy aim of reducing inappropriate hospital admissions by spreading ‘best practice’ (introducing RRTs across Scotland), as part of a broader multiple case study of organisational learning. Using an ethnographic approach the study was conducted among three Scottish primary care teams over two years (2005–2006). Teams were purposively sampled (Mason, 1996) to ensure varied professional and organisational mixes, geographical settings, patient populations and
Responses to the vignette
The primary care teams discussed the vignette five years after the introduction of RRTs had become a policy recommendation.
In the Harebell area, an RRT had been partially introduced but primary care personnel would not call upon it in the vignette situation, because RRT staff were unavailable between 6pm and 8am to organise team input. Patients would be admitted to DGH1 overnight and referred to the DGH outreach service which helped support people at home thereafter, which constituted a form of
Contradictions and tensions in the object of activity
Our data consistently indicated that clinicians and managers associated with all teams strongly endorsed the goal of avoiding unnecessary hospital admissions of older people who were not seriously unwell, by providing the additional care and support they needed at home. However, this goal proved difficult to achieve and RRTs – insofar as they were introduced - did not have the transformative effects envisaged by policy makers.
The planned introduction of RRTs was consistent with a broader policy
Discussion
From a KT perspective, the problems of implementing the RRT solution may indicate failure of those along the communication chain (from policy through management to clinical practice) to appreciate and enact best practice fully. The politics, disputes over accountability and persistence of GPs in making hospital referrals could suggest breakdown either in the transfer of the knowledge or the translation of its meaning across different groups (or both). Breakdowns in the flow could be deliberate
Conclusion
Our aim was to develop and illustrate the utility of AT in producing insights for addressing complex problems in healthcare. AT can accommodate the uncertain, unpredictable nature of healthcare service provision, policy making and management. It anticipates unintended consequences (Hinings et al., 2003) because of competing priorities entailed in the co-constitution of an object of activity, even in settings where there is apparent agreement about it. This supports a tentative, ‘trying out’
Acknowledgements
G. Greig: Original empirical work funded by Chief Scientist Office, Scottish Executive Health Dept. Greig, G., Beech, N. and Entwistle V.: Paper prepared during time funded by UK ESRC Post Doctoral Fellowship Grant, ref PTA-026-27-2255; N. Beech: paper prepared through grant from UK ESRC grant: RES-331-27-0065.
References (71)
- et al.
Knowledge transfer: a basis for competitive advantage in firms
Organizational Behaviour and Human Decision Processes
(2000) - et al.
Theorising big IT programmes in healthcare: strong structuration theory meets actor-network theory
Social Science & Medicine
(2010) The genealogy of lean production
Journal of Operations Management
(2007)- et al.
Behind the scenes in health care improvement: the complex structures and emergent strategies of implementation science
Social Science & Medicine
(2008) The process of knowledge transfer: a diachronic analysis of stickiness
Organizational Behaviour and Human Decision Processes
(2000)- et al.
The persistence and transfer of learning in industrial settings
Management Science
(1990) One developmental line in European activity theories
- et al.
Knowledge management and communities of practice in the private sector: lessons for modernizing the National Health Service in England and Wales
Public Administration
(2002) Double bind
- et al.
Paradox as an invitation to act in problematic change situations
Human Relations
(2004)